THE COMMONWEALTH FUND Patients with Complex Care Needs: Coordination, Safety and Medical Homes Findings from the Commonwealth Fund 2011 International Health.

THE COMMONWEALTH

FUND

Patients with Complex Care Needs:

Coordination, Safety and Medical Homes

Findings from the Commonwealth Fund 2011 International Health Policy Survey of Sicker Adults in Eleven Countries and

Health Affairs article, Nov. 2011

Webinar: January 11, 2012

Cathy Schoen

Senior Vice President, The Commonwealth Fund

Key Findings2

• Care is often poorly coordinated for patients with complex care needs – but wide differences emerge across country

• Medical homes make a difference

• In all countries sicker adults with a “medical home” have more positive care experiences and are less likely to experience coordination gaps or medical errors

• Swiss and the United Kingdom patients most likely to have medical homes; have among the lowest rates of access concerns, coordination gaps or errors across countries

• United States’ chronically ill patients stand out for access problems because of cost and difficulty paying medical bills

• U.S. also among highest for errors and coordination gaps

• Survey of “Sicker Adults”, 11 Countries (see last page for details)• Australia, Canada, France, Germany, Netherlands, New Zealand,

Norway, Sweden, Switzerland, U.K., and U.S.

• March-June 2011 Phone survey of 18,000 adults who reported fair/poor health, recent hospital, or surgery, or serious illness

3Health Spending per Capita, 2009

Adjusted for Differences in Cost of Living

* 2008

Source: OECD Health Data 2011 (June 2011).

% GDP

Cost-Related Access Problems in the Past Year, Sicker Adults 2011

4

Percent of adults who went without care because of cost in past year *

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

* Did not see doctor when sick, get recommended care, or fill prescription or skipped doses because of costs.

5Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year

Percent

Spent more than US$1,000OOP Costs


Serious Problems Paying or Unable to Pay Medical Bills

6Access to Doctor or Nurse Last Time Sick or Needed Care

Percent

Same- or next-day appointment

Waited six days or more


7

After-Hours Care and Emergency Room Use

Percent

Difficulty Getting After-Hours Care Without Going to the ER

Used ER in Past Two Years


8

Waited Less Than a Month to See Specialist

Percent


Base: Saw or needed to see a specialist in the past 2 years.

9

Experienced Coordination Gaps in Past Two Years

Percent


* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

10

Percent


* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.

Gaps in Hospital or Surgery Discharge Planning in Past Two Years

11Experienced Medical, Medication, or Lab Test Errors in Past Two Years


* Reported medical mistake, given wrong medication or dose, lab test error, or delay receiving abnormal test results.

Percent*

Patient Engagement in Care Management for Chronic Condition

Percent reported professional in past year has:

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Discussed your main goals/ priorities

63 67 42 59 67 62 51 36 81 78 76

Helped make treatment plan you could carry out in daily life

61 63 53 49 52 58 41 40 74 80 71

Given clear instructions on symptoms and when to seek care

66 66 56 64 64 63 44 49 84 80 75

Yes to all three 48 49 30 41 42 45 23 22 67 69 58

12


Base: Has chronic condition.

Patients with a Regular Doctor vs. Medical Home13

Percent

Patients with a medical home have a regular practice who is accessible, knows their medical history, and helps coordinate their care.


14Experienced Coordination Gaps in Past Two Years,

by Medical HomePercent*


* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.

15Hospital or Surgery Discharge Gap in Past Two Years,

by Medical Home


* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.

Percent*


16


Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home

* Reported medical mistake, medication error, and/or lab test error or delay in past two years.

Percent*


Patient Engagement in Care Management for Chronic Condition, by Medical Home

17


Base: Has chronic condition.

Percent reporting positive patient engagement in managing chronic condition*

* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.


18


Rated Quality of Care in Past Year as “Excellent" or “Very Good,” by Medical Home

Percent


U.S. Adults: Affordability, Access, and Coordination Experiences in the Past Year, by Age and Insurance


19

Percent

20

Cross-Cutting Themes and Implications

• Room for improvement in all countries

– Improving care coordination and system integration

• Primary care “medical homes” make a difference in all countries

– Patients in the U.K. and Switzerland often have more positive experiences despite very different systems

• U.S. is an outlier on access and affordability

– Concerns concentrated in the under-65 population; Medicare more positive experiences

– Other countries spend far less yet provide more comprehensive insurance and protective benefits

– Policies need to maintain Affordable Care Act commitment to access and affordability; avoid shifting costs to patients

• Opportunities to learn as we confront often similar challenges in diverse health care systems

2011 International Health Policy Survey: Description21

• Telephone survey of representative samples of sicker adults ages 18 and older conducted from March to June 2011

• Sicker adults included: fair or poor health; had surgery or been hospitalized in past 2 years; or received care for serious or chronic illness, injury, or disability in past year

• Final Samples 18,000 in 11 Countries

• 1,500 Australia, 3,958 Canada, 1,001 France, 1,200 Germany, 1,000 Netherlands, 750 New Zealand, 753 Norway, 4,804 Sweden, 1,500 Switzerland, 1,001 U.K., and 1,200 U.S.

• Conducted by Harris Interactive and country contractors

• Results published in Health Affairs

• C. Schoen, R. Osborn, D. Squires, et al. “ New 2011 Survey of Patients with Complex Care Needs in Eleven Countries Finds Care is Often Poorly Coordinated”, Health Affairs, Web First, 11/9/2011, Print December 2011 Vol. 30(12):2437-2447.

22

2011 Survey Profile of Sicker Adults

Percent AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Age 50 or older 57 50 54 60 57 54 60 58 63 62 56Has 2+ chronic conditions (out of 8)

44 41 34 42 34 34 35 26 37 45 53

Health care usein past 2 years:

Hospitalized 54 37 51 43 40 50 46 48 54 48 40Surgery 43 37 36 37 39 46 38 35 46 41 38Saw 4+ doctors 32 21 23 36 24 26 19 23 6 16 21

Taking 4+ prescription medications regularly

28 30 26 24 31 27 29 30 24 35 37


2323

Acknowledgments and Cofunders

• Australia: Bureau of Health Information

• Canada: Health Council of Canada, Ontario Quality Council, Quebec Health Commission, Health Quality Council of Alberta

• France: Haute Authorité de Santé (HAS), Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés (CNAMTS)

• Germany: German National Institute for Quality Measurement in Health Care

• Netherlands: Dutch Ministry of Health, Welfare and Sport, and Scientific Institute for Quality of Healthcare, Radboud University Nijmegen

• Norway: Norwegian Knowledge Centre for the Health Services

• Sweden: Swedish Ministry of Health and Social Affairs

• Switzerland: Federal Office of Public Health

• United Kingdom: Health Foundation

Thanks to coauthors David Squires, Michelle M. Doty, Roz Pierson, and Sandra Applebaum, and to Harris Interactive, Inc., and contractors for conducting the survey. Published in Health Affairs as: “New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds Care Is Often Poorly Coordinated,” Web First, November 9, 2011.

THE COMMONWEALTH FUND Patients with Complex Care Needs: Coordination, Safety and Medical Homes Findings from the Commonwealth Fund 2011 International Health.

Documents

countries sicker adults

commonwealth fund slide

percent of adults

care percent

commonwealth fund patients

medical home percent

years percent source

specialist care